Section DHS 75.24 - Service operations(1) SCREENING. (a) A service shall complete an initial screening for an individual that presents for services. The screening shall include all of the following:1. Sufficient assessment of dimensional risk and severity of need to determine preliminary level of care.2. A determination of the patient's needs for immediate services related to withdrawal risk, acute intoxication, overdose risk, induction of pharmacotherapy, or emergency medical needs.3. An assessment of the patient's suicide risk.(b) A screening is preliminary, and is either confirmed or modified based on completion of the full assessment and ASAM or other department-approved level of care placement criteria.(c) The screening completed under this subsection may be combined with a more comprehensive assessment.(2) EMERGENCY SERVICES. If a need is identified for immediate services related to withdrawal, acute intoxication, overdose, or other reason, the service may initiate treatment prior to completion of the comprehensive assessment or treatment plan. The patient's record for emergency services shall include documentation of all of the following:(a) A preliminary treatment plan for the patient.(b) A consent for services to be received, signed by the patient or the patient's legal guardian.(c) A progress note for all services delivered to the patient.(d) A reason for the initiation of emergency services and a completed initial screening that evaluates biomedical, mental health, and substance use indicators, and guides decision-making regarding the initial level of care placement and referral.(3) AFTER HOURS EMERGENCY RESPONSE. A service shall have a written policy and procedure for how the clinic will provide or arrange for, the provision of services to address a patient's behavioral health emergency or crisis during hours when its offices are closed, or when staff members are not available to provide behavioral health services.(4) SAFETY PLANNING. (a) When a patient's pattern of behavior or acute symptoms of a substance use or mental health disorder indicate the likelihood for significant, imminent harm to the individual or others, including affected family members, the service shall develop a safety plan within 24 hours of the contact.(b) The service shall have written policies and procedures that outline the requirements and process for safety planning.(5) OPIOID OVERDOSE REVERSAL. (a) A service shall have Naloxone on-site at each facility and branch location, to be administered in the event of an opioid overdose.(b) Naloxone medication shall be maintained and unexpired, and shall be stored in an accessible location.(c) The service shall have written policies and procedures for administration of Naloxone by service staff.(d) The service shall train all staff in recognition of overdose symptoms and administration of Naloxone.(e) Administration of Naloxone by the service to any individual shall be documented in the clinical record or in a facility incident report.(6) SERVICE DELIVERY FOR INTOXICATED INDIVIDUALS. A service shall have written policies and procedures regarding clinically-appropriate response and services for individuals that present with symptoms of acute intoxication, withdrawal, or at risk of withdrawal. The policies and procedures shall include the following: (a) The process for obtaining medical consultation, when indicated.(b) The process for admitting the patient to a higher level of care, withdrawal management service, or direct linkage to medical services, when indicated.(c) The process for ensuring the safety of an intoxicated individual or persons experiencing withdrawal, including an individual operating while intoxicated.(d) The process for follow-up and treatment engagement after an intervention for acute intoxication or withdrawal.(7) TOBACCO USE DISORDER TREATMENT AND SMOKE-FREE FACILITY. A service shall have written policies outlining the service's approach to assessment and treatment for concurrent tobacco use disorders, and the facility's policy regarding a smoke-free environment.(8) CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES. A service shall have a written policy and procedure for assessing the cultural and linguistic needs of the population to be served, and to ensure that services are responsive and appropriate to the cultural and linguistic needs of the community to be served.(9) INTAKE AND ADMISSION. (a) A service shall have written policies and procedures for intake, including all of the following: 1. A written consent for treatment, which shall be signed by the prospective patient before admission is completed.2. Information concerning communicable illnesses, such as sexually transmitted infections, hepatitis, tuberculosis, and HIV, and shall refer patients with communicable illness for treatment when appropriate.3. Policies regarding admission of a patient under court order, that shall be in accordance with ss. 51.15, 51.20, and 51.45 (12), Stats.4. A method for informing the patient about, and obtaining the patient's signed acknowledgment of having been informed and understanding all of the following: a. The general nature and purpose of the service.b. Patient rights and the protection of privacy provided by confidentiality laws.c. Service regulations governing patient conduct, the types of infractions that result in corrective action or discharge from the service, and the process for review or appeal.d. The hours during which services are available.e. Procedures for follow-up after discharge.f. Information about the cost of treatment, who will be billed, and the accepted methods of payment if the patient will be billed.g. Sources of collateral information that may be used for screening and assessment.(b) If the patient is seeking treatment related to opioid use, and the service does not provide medication-assisted treatment for patients with opioid use disorders, the service shall provide information about the benefits and effectiveness of medication as an effective treatment for opioid use disorders. If the patient is not already receiving medication treatment, the service shall obtain the patient's written consent to participate in non-medication treatment, shall provide a referral to a service that offers medication-assisted treatment for opioid use disorders.(10) FIRST PRIORITY FOR SERVICES. (a) A service shall prioritize admission in the following order: 1. First, pregnant women who inject drugs.2. Second, pregnant women that use drugs or alcohol.3. Third, persons who inject drugs.(b) When a waitlist exists for services for pregnant women, the service shall either initiate interim services or notify the department within 2 business days.(c) When a waitlist exists for services for individuals who inject drugs, the service shall either initiate interim services or notify the department within 14 business days.(11) CLINICAL ASSESSMENT. (a) Clinical staff of a service, operating within the scope of their knowledge and practice, shall assess each patient through interviews, information obtained during intake, counselor observation, and collateral information.(b) The service shall promote assessments that are trauma-informed.(c) If a comprehensive clinical assessment has been conducted by a referring substance use treatment service and is less than 90 days old, the assessment may be utilized in lieu of conducting another one.(d) Information for the assessment shall include the following:1. The clinical staff's evaluation of the patient, and documentation of psychological, social, and physiological signs and symptoms of substance use and/or mental health disorders, based on criteria in the DSM.2. The summarized results of all psychometric, cognitive, vocational, and physical examinations provided as part of the assessment.3. History of substance use that includes all of the following: b. Duration of use for each substance.c. Frequency and amount of use.d. Method of administration.e. Status of use immediately prior to entering into treatment.f. Consequences and effects of use.g. Withdrawal and overdose history.4. Documentation about the current mental and physical health status of the patient.5. Psychosocial history information shall include all of the following areas that relate to the patient's presenting problem: b. Significant relationships.i. Other factors that appear to have a relationship to the patient's substance use and physical and mental health.6. The clinical assessment shall include any collateral information gathered during the clinical assessment. Collateral information may include one of more of the following: a. Review of Wisconsin Prescription Drug Monitoring Program database.b. Records of the patient's legal history.c. Information from referral sources.d. Consultation with the patient's physician or other medical or behavioral health provider.e. Consultation with department of corrections or child protective services when applicable.f. Information from the patient's family or significant others.g. Results of toxicology testing.7. Level of care recommendation based on ASAM or other department-approved placement criteria.(e) If no collateral information is obtained to inform the assessment, the service shall document the reason for not including collateral information.(f) The clinical staff's recommendations for treatment shall be included in a summary of the assessment that is consistent with diagnosis and level of care placement criteria.(g) If an assessing substance abuse counselor identifies symptoms of a mental health disorder during the assessment process, the substance abuse counselor shall refer the individual to an appropriately credentialed provider for a comprehensive mental health assessment, unless the substance abuse counselor is also a licensed mental health professional.(h) If the assessing clinical staff identifies symptoms of a physical health problem during the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.(i) If the assessing clinical staff identifies that an individual is pregnant at the time of the assessment, the service shall make a referral for prenatal care or ensure that the patient is already receiving prenatal care, and document efforts to coordinate care with prenatal care providers.(j) In the event that the assessed level of care is not available, a service shall: 1. Document accurately the level of care indicated by the clinical assessment.2. Indicate on the treatment plan what alternative level of care is available or agreed upon.3. Identify on the treatment plan what efforts will be made to access the appropriate level of care, additional services or supports that will be offered to bridge the gap in level of care, and ongoing assessment for clinical needs and level of care review.(k) For assessments completed by a substance abuse counselor in-training or a graduate student QTT, the assessment and recommendations shall be reviewed and signed by the clinical supervisor within 7 days of the assessment date.(l) For a patient receiving mental health services under s. DHS 75.50 or 75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria is not required.(12) REFERRAL. (a) A service shall have written policies and procedures for referring patients to other service providers and for coordinating care with other providers.(b) Policies and procedures shall include a description of follow-up activities to be completed to support that recommended care is received.(c) Follow-up shall occur within one week of the referral.(13) TREATMENT PLAN. (a) Clinical staff of a service shall develop a treatment plan for each patient.(b) A patient's treatment plan shall represent an agreement between the service and the patient regarding needs identified in the clinical assessment, the patient's identified treatment goals, and treatment interventions and resources to be applied.(c) When feasible, the treatment plan shall be developed in collaboration and with input from the patient's family or significant other, or other supportive persons identified by the patient.(d) The treatment plan shall be signed by the patient, the primary counselor, and other behavioral health clinical staff, identified in the treatment plan.(e) A treatment plan completed by a substance abuse counselor in-training or a graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the development of the plan or the next treatment plan review, whichever is earlier.(f) The content of the treatment plan shall describe the identified needs and specify individualized treatment goals that are expressed in behavioral and measurable terms.(g) The treatment plan shall specify each intervention applied to reach the treatment goals.(h) The treatment plan shall be reviewed at the interval required by the patient's level of care or based on the patient's needs and clinical indication. The review shall be documented with a summary of progress and the signature of the patient and primary counselor.(i) The treatment plan review shall include an updated level of care assessment which follows ASAM or other department-approved placement criteria and recommends continued stay, transfer, or discharge.(j) An updated treatment plan shall be established during the review if there is a change in the patient's needs, goals, or interventions and resources to be applied. The updated treatment plan shall be signed by the patient, the primary counselor, and any other behavioral health clinical staff identified in the treatment plan.(k) Treatment plan reviews and updates completed by a substance abuse counselor in-training or graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the review and update.(l) For patients with co-occurring disorders receiving services under ss. DHS 75.50, 75.51, 75.52, 75.54, 75.55, 75.56, and 75.59 service shall assign dually-credentialed clinicians whenever possible. When this is not possible, the service shall ensure that mental health needs and substance use needs are included in the treatment plan, and met by appropriately credentialed personnel.(m) For a patient receiving mental health services under s. DHS 75.50 or 75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria and review is not required.(14) CLINICAL CONSULTATION.(a) A service shall have a written policy and procedure that outlines the structure for clinical consultation.(b) Clinical consultation applies to all clinical staff of a service.(c) Clinical consultation shall be documented in the patient's case record.(d) Clinical consultation for unlicensed staff shall be completed with a clinical supervisor and shall be documented with the clinical supervisor's signature. Clinical consultation for licensed professionals may occur with a clinical supervisor or another licensed professional who is a staff of the service.(e) Clinical consultation is required for any of the following:1. When a patient's substance use or mental health poses a significant risk to the individual, their family, or the community.2. When a safety plan has been developed, per s. DHS 75.24 (4).3. When an individual's symptoms, pattern of substance use, risk level, or placement criteria indicate transfer to a higher level of care.(f) When a safety plan requires ongoing monitoring, clinical consultation shall be completed at clinically-determined intervals until the risk level is reduced or appropriately managed with services or collateral supports.(g) When the recommended level of care cannot be determined, or is not available, or the individual has declined the recommended level of care, clinical consultation shall be completed at clinically-determined intervals until the appropriate level of care is determined, or obtained, or the individual's risk level decreases.(15) CLINICAL STAFFING. (a) A service shall have a written policy and procedure that outlines the structure for clinical staffing.(b) Clinical staffing applies to all clinical staff of a service, and includes the clinical supervisor and medical personnel. Clinical staffing is facilitated at intervals appropriate to the individual's needs and as prescribed based on the level of care.(c) For clinical staffing required under ss. DHS 75.49 to 75.59, the following shall apply: 1. Clinical staffing shall include the clinical supervisor of the service.2. Clinical staffing shall include a patient's prescriber or medical personnel, if applicable.3. Clinical staffing may be combined with treatment plan review and level of care review.4. Clinical staffing shall be documented in the patient's clinical record.(16) PROGRESS NOTES. (a) A service shall document in the patient's record each contact the service has with a patient or with a collateral source.(b) Notes shall be entered by the staff member providing the service to document the content of the contact with the patient or a collateral source; or, if notes are entered by a designee, this must be specified.(c) Progress notes shall include chronological documentation of treatment that is directly related to the patient's treatment plan, and documentation of the patient's response to treatment.(d) The person making the entry shall sign and date the note, and if a designee, shall indicate who provided the service.(17) GROUP COUNSELING. (a) A service may offer group counseling.(b) A service shall have written policies and procedures regarding group counseling that include, at minimum, the following: 1. Participant confidentiality.2. Group rules for safety.3. Consideration of needs related to special populations or considerations for co-mingled groups.4. Assurance that groups are trauma-informed.(c) Each group therapy contact shall be documented as a progress note in each patient's case record.(18) FAMILY SERVICES. (a) When requested by a patient's affected family member or significant other, the service shall offer or refer for supportive services, such as counseling, support groups, or education.(b) A service shall involve a patient's family members and significant others in assessment, treatment planning, transfers of care, safety planning, and discharge whenever feasible.(c) A service shall have written policies and procedures to address confidentiality, conflicts of interest, and ethics related to family services.(19) MEDICAL SERVICES. (a) All medical services provided under this chapter shall be provided by appropriately credentialed staff operating within their scope of practice,(b) Prescribers providing substance use treatment services or supervision of substance use treatment services shall be knowledgeable in addiction treatment.(c) For medical needs of a patient that exceed the scope of the service under this chapter, the service shall coordinate with appropriate medical providers.(d) A service may offer medication management for treatment of substance use disorders or mental health disorders. A service shall have written policies and procedures for medication management services, including:1. Prescribing policies and practices.2. Prescriber checks and use of the Wisconsin Prescription Drug Monitoring Program database.3. Procedures for obtaining and updating patient consents for medications received.4. Procedures for reporting and reviewing medication errors via facility incident reports or other documentation.(e) When a patient's treatment includes medication management, it shall be documented as a goal in the patient's treatment plan. The treatment plan shall be signed by the prescriber.(f) If a patient is prescribed medication as part of the treatment plan, the service shall obtain a separate consent that indicates that the prescriber has explained to the patient, or the patient's legal representative, if applicable, the nature, risks and benefits of the medication and that the patient, or legal representative, understands the explanation and consents to the use of the medication.(g) A service shall maintain medication records that allow for ongoing monitoring of any medication prescribed or administered by the service, and documentation of any adverse drug reactions or medication errors. Medication orders shall specify the name of the medication, dose, route of administration, frequency of administration, name of the prescriber who prescribed the medication, prescriber signature, and staff administering the medication, if applicable.(h) A service that receives, stores, or dispenses medications shall have written policies and procedures regarding storage, dispensing, and disposal of medications, including: 1. Patient name, medication name, amount of medication, dosage, date of receipt, and date of dispensing or disposal.2. Safeguards to prevent the diversion of medication.(i) A non-residential service that receives, stores, or dispenses medications shall comply with 21 CFR 1301.72. The medication storage area shall be clean, and shall be separated by a wall from any restroom, cleaning products, or any food-preparation or storage area.(j) A residential service under ss. DHS 75.53 to 75.58, shall follow the requirements for medication storage provided in s. DHS 75.39.(20) DRUG TESTING SERVICES. (a) A service shall have written policies and procedures for drug testing, breath analysis, and toxicology services. Patients of a service shall be informed of these policies and procedures upon admission.(b) A service may utilize drug testing information in conjunction with patient self-report, behavioral observations, collateral information, and clinical assessment to make determinations regarding patient care.(c) A service shall have a method for obtaining confirmation of drug testing results.(d) A service shall inform patients of the costs for drug testing services.(e) A service shall obtain informed consent before releasing patient drug testing results. The service is responsible for ensuring that the patient understands possible consequences of disclosure of drug testing information.(21) TRANSFER. If the service transfers a patient to another provider or if a change is made in the patient's level of care, the transfer or change in the level of care shall be documented in the patient's case record. A transfer summary shall be entered into the patient's case record, including the following:(a) The date of the transfer.(b) A completed copy of the standardized placement criteria and level of care recommended.(c) Documentation of communication and follow-up that ensures continuity of care from one provider or level of care to another.(22) DISCHARGE. (a) A patient may be discharged from a service for any of the following reasons:1. Successful completion of recommended services and treatment plan goals.2. No longer meeting placement criteria for any level of care in the substance use treatment system.3. Patient discontinuation of services.4. Administrative discharge.(b) A service shall have written policies and procedures for the service director's review of administrative discharge or discharges due to patient dissatisfaction or attrition.(c) A service shall have written policies and procedures for the service director's review of discharges due to patient death from overdose.(d) A discharge summary shall be entered into the patient's case record, including the following: 1. A completed copy of the standardized placement criteria and level of care indicated.2. Recommendations regarding care after discharge.3. A description of the reasons for discharge.4. The patient's treatment status and condition at discharge.5. A final evaluation of the patient's progress toward the goals identified in the treatment plan.(e) The discharge summary shall include a notation indicating the reason that any items from par. (d) were not able to be provided at discharge, if applicable.(23) CONTINUING CARE SERVICES. (a) An outpatient substance use treatment service under s. DHS 75.49 or an outpatient integrated behavioral health treatment service under s. DHS 75.50 may provide ongoing recovery monitoring, continuing care, aftercare, or behavioral health check-ups at the outpatient level of care.(b) A patient who has completed services and been discharged may continue contact with the provider at agreed upon intervals without completing a new clinical assessment, intake, or treatment plan.(c) Each contact with a patient in continuing care service shall be documented in a progress note.(d) If, during the provision of continuing care services, there is indication that a higher level of care or additional services may be needed due to substance use relapse or other behavioral, mental, or physical health indicators, the service shall complete an updated level of care placement criteria screening or updated mental health assessment and make appropriate referrals and transfers of care.(e) The continuing care service shall obtain valid and updated releases of information for any referrals or collateral communications regarding patients in continuing care.(f) Continuing care services may not provide medical services.(g) The death of a patient in continuing care services shall be subject to reporting as specified in s. DHS 75.10 (1).Wis. Admin. Code Department of Health Services DHS 75.24
Amended by, correction in (11) (b) made under s. 35.17, Stats., Register November 2021 No. 791, eff. 12/1/2021Adopted by, CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (11) (L), (13) (m), (14) (e) 2., (g) made under s. 35.17, Stats., and correction in numbering in (21) made under s. 13.92(4) (b) 1, Stats., Register October 2021 No. 790, eff. 10/1/2022Amended by, CR 23-053: am. (12) (a) Register September 2023 No. 813, eff. 10/1/2023This section is created eff. 10-1-22 by CR 20-047.